Gastrointestinal Toxicity Of Nonsteroidal Antiinflammatory Drugs

Wolfe MM, et al.

N Engl J Med. 1999 Jun 17;340(24):1888-99. Review.

This review presents current knowledge on nonsteroidal antiinflammatory drugs (NSAID)-related gastrointestinal toxicity. NSAIDs were developed in the 1970s as an alternative to aspirin and its side effects, most notably gastric ulcers, and became in the following decades one of the most frequently used class of drugs.

 Every year, in the U.S., over 70 million prescriptions are written for NSAIDs,
and over 30 billion tablets are sold over-the-counter. Toxicity from these drugs is substantial. Particularly affected is the gastrointestinal system. Dyspepsia occurs in 5-50% of patients, and causes discontinuation of treatment within 6 months of initiation in 5-15% of individuals. It has been estimated that for every 1000 rheumatoid arthritis patients using NSAIDs for a year, there are 13 hospitalizations
for serious gastrointestinal complications. There are approximately 13 million individuals who use NSAIDs by prescription.

Extrapolation of these data reveals that every year in the U.S., at least 103,000 individuals are hospitalized for serious gastrointestinal toxicity from NSAID use, and an estimated 16,500 will not survive the complication. Based on these estimates, death from gastrointestinal complications of NSAIDs represents the 15th cause of death in the U.S. This means that every year NSAIDs kill
approximately the same number of people as does AIDS, and considerably more people than does asthma, cervical cancer and Hodgkin's disease combined.

These figures are conservative since they do not take in account users of over-the-counter NSAIDs. What is even more worrisome is that patients are by large, unaware of the risks associated with the use of these drugs. A recent survey revealed that 75% of patients taking NSAIDs regularly, were not aware or were not preoccupied with the possibility of gastrointestinal complications, and almost two thirds of them incorrectly believed that there would be warning signs preceding the insurgence of gastrointestinal complications. The cost of NSAID gastrointestinal toxicity is high. Each hospitalization costs approximately $15,000 to $20,000, leading to total annual health care expenses exceeding $2 billion.